I am over the age of ________________
(eighteen) years, and, on ______________,

I transmitted the ________________ (describe
the paper or document mailed).One
copyof this paper or document, which
is attached to this affidavit, was sent to the addressee set forth below.The paper or document was sent by
depositing a copy enclosed in the prescribed wrapping of _____________ (name of
private delivery service), at the office of __________ (name of private
delivery service), located at
______________________________________________________.The address on the package is as follows: ____________________________________
(name and address of addressee).

A
true and correct copy of the receipt for delivery charges of
____________________

(name
of private delivery service) for the delivery of above-described ______________
(describe paper or document) is attached to this instrument.